Clavicle Fractures

Case Review #3

The Clavicle

•A long, curved bone that sits nearly horizontal•Forms the anterior portion of the shoulder girdle•Bony connection between the upper limb and thorax•Lateral motion of the arms

Functions of the ClavicleRigid support for scapula

and armProtection for NV bundle

and lung apexMotion and stabilityTransmission of physical

impactsMuscle attachments

Clavicle FracturesMost common acute shoulder injuryMost common fracture in children and young adultsEasily fractured

Classification Systems: Allman and Neer

Allman Classification

Neer ClassificationGroup 2 Type 1 •Intact ligaments

Group 2 Type 2•Conoid and Trapezoid ligaments are intact•Proximal segment is displaced

Group 2 Type 2B•Conoid ligament is ruptured•Trapezoid ligament remains intact•Proximal segment is displaced

How do clavicle fractures happen?

Direct fall onto shoulderContact sportsFOOSH – in a small % of casesMVAChild birth

When the clavicle fractures.....

Elevation of the medial fragment

Drooping of the arm

Unable to sustain the weight of the

arm

The Patient.....An 8 yr old maleFell into a ditch

May 1, 2013Mild displacement of the distal 1/3 right clavicle fracture

June 13, 2013Follow up visit to the Ortho ClinicHealing fracture of the lateral 1/3 with mild deformity & displacement

PACS Image 478 0856.001K

Patient Care Concerns....

Patient may be on a stretcher.....Pain, bleeding, swelling, bruising, tenting.....Immobilized.....Scared.....Vital Signs.....ABC’s

Treatment Plans and Follow up.......

Diagnostic Imaging......

Views of the Clavicle:APAP Axial (15-30 degree cephalic)

If Pneumothorax or Hemothorax is suspected......

Non-operative Treatments.....Immobilization (sling, figure 8 bracing).....

Non-operative Treatments cont’d....

Physiotherapy

Pendulum ExercisesBall Grip

One should avoid:•Arm raising•Lifting more than 5 lbs

•Use ice to reduce pain, swelling and inflammation•Good body mechanics•immobilization

Non-operative Treatments con’t....

Follow up visits with doctor/orthopedic surgeonSubsequent imaging to check for healing progressPain management

Surgery may be warranted if......

Comminuted fractures Clavicle foreshorteningOpen fractureNeurovascular involvementNon-union of boneInterference with normal functioning

Operative Techniques

Plate Fixation Intramedullary Fixation

Some interesting facts.......

Did you know.....The clavicle is reliable in determining gender differences........

In the male:•Longer and thicker•Acromial end is slightly higher than the sternal end

In the female:•Thinner an shorter•Smoother and lighter•Acromial end is slightly below level of sternal end

The clavicle can also be useful for.....

Bone Age Assessment

Distal Clavicular OsteolysisOveruse injuryConsistent with stress fracturesCommon with weightliftersTrauma can precipitate developmentJoint space enlargement

Thoracic Outlet Syndrome

Common causes:TraumaCallus formationRepetitive injuryInjury from years agoAnatomical defects

Blood vessels and nerves become compressed causing pain and numbness

Medial clavicle fractures can be very dangerous....

•A 19 yr old male on a motorbike involved in a head on collision

•Chest x-ray revealed a massive left Pneumo-hemothorax and mediastinal shift

•Neurovascular damage

Fracture of the medial 1/3 clavicle with significant displacement

References.....•Clavicle fracture. (2013, July 16). Retrieved from http://www.patient.co.uk/doctor/Fractured- Clavicle.htm •Clavicle fracture classification. (2013, July 16). Retrieved from http://eorif.com/clavicle-fracture-classification •Daruwalla, Z., Courtis, P., Fitzpatrick, C., Fitzpatrick, D., & Mullett, H. (2010). An application of principle component analysis to the clavicle and clavicle fixation devices. Retrieved from http://openi.nlm.nih.gov/detailedresult.php?img=3003245_1749-799X-5-21-11&req=4 •Distal clavicular osteolysis. (2010). Retrieved from http://www.wosm.com/index.php/orthopaedic-services-/shoulder/141-distal-clavicular-osteolysis •Faisham, W. I., Mohammad, P., Juhara, H., Munirah, N. M., Shansulkamaruljan, H., & Ziyadi, G. M. (2011, June). Clavicle fracture and subclavian vessels disruption with massive haemothorax mimic intrathoracic injury. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3216210/ •Rubino, MD, L. J. (2012, March 7). Clavicle fractures. Retrieved from http://emedicine.medscape.com/article/1260953-overview •Thoracic outlet syndrome. (2013, July 16). Retrieved from http://www.mayoclinic.com/health/thoracic-outlet-syndrome/DS00800/DSECTION=causes